Mental health literacy for supporting children: the need for a new field of research and intervention
Authors: Laura M. Hart, Anthony F. Jorm, Catherine L. Johnson, Lucy A. Tully, Emma Austen, Karen Gregg, Amy J. Morgan
Journal: World Psychiatry (2023)

The concept of "mental health literacy" (MHL) was first defined in 1997 as the "knowledge and beliefs about mental disorders which aid their recognition, management or prevention"1. MHL originally encompassed: a) the ability to recognize specific disorders; b) knowing how to seek mental health information; c) knowledge of risk factors and causes; d) knowledge of self-help and of professional help available; and e) attitudes that promote recognition and appropriate help seeking. Later revisions added: f) knowledge of how to prevent mental disorders; g) recognition of when a disorder is developing (i.e., early identification); and h) first aid skills to support others affected by mental health problems2. Some scholars also include: i) knowledge for mental health promotion3. Since its articulation, MHL has been instrumental in the creation of interventions, policy and funding for mental health in many countries. Much of the research influenced by the concept of MHL has focussed on adolescents, as this is the period of life where mental disorders often first develop, and schools provide a suitable setting for promoting adolescents' MHL4. However, we believe that there is an urgent need to define a new field of research focussed on the knowledge and beliefs of adults about mental ill-health in school-aged children (those around 5 to 12 years), to aid better recognition, management and prevention. The rationale for a separate field is clear: the MHL required to recognize, manage and prevent mental ill-health in childhood is unique to this life stage. The diagnoses and symptom profiles, the help-seeking pathways, the modifiable risk and protective factors, as well as stigmatizing attitudes, are particular to pre-adolescent children and thus require tailored research methods and interventions. Population-based surveys indicate important differences in the psychiatric epidemiology of children aged 5 to 12 years, as compared to adolescents aged 13-18. For example, attention-deficit/hyperactivity disorder (ADHD), as well as separation and phobia-related anxiety disorders, are much more prevalent among younger children, particularly boys, whereas depression and social phobias take centre stage in adolescence, particularly among girls5. The clinical interventions required across the childhood and adolescent years are also different. Parents play a much larger role in treatment for children than for adolescents; many frontline treatments for pre-adolescents involve parent training (e.g., psychoeducation or parent management training), or combined parent and child psychological therapy. Frontline treatments for adolescents, instead, are more likely to involve individual therapy or pharmacotherapy6. Relatedly, the help-seeking pathways and access to treatment for children versus adolescents (or adults) are also distinct. For diagnosing child conditions, multi-informant assessments are preferred, whereas for adolescents this is not as common6. It is possible for adolescents to access mental health care through their school, community-based primary care, or sometimes even private providers, without the knowledge or input of their guardians. This is not possible for children, who are totally dependent on their caregiving adults to recognize mental ill-health and engage in appropriate help seeking for it. We therefore propose a new concept – mental health literacy for supporting children (MHLSC) – to refer to adults' knowledge and beliefs that support action to prevent or manage mental health problems in children. We suggest that MHLSC involves adults': a) ability to recognize when a child is developing a mental health problem (e.g., not coping, experiencing increasing distress, or difficulty functioning as expected); b) knowledge and attitudes about how to seek and engage critically with information about child mental health, risk factors and causes of mental health problems in children, and sources of formal and informal help for both the child and caregivers; and c) ability to communicate about child mental health and supportive strategies with the child in a developmentally-appropriate manner, and with other adults who care for or are responsible for the child. Because children may not have the capacity to understand their mental health problem, manage it, or seek help for it, the MHL that adults need to support children with mental ill-health is more complex than adolescent or adult MHL. We also believe that it is important to distinguish between the knowledge and beliefs which adults hold about child mental health problems (MHLSC), and the knowledge and beliefs that children hold about their own mental health (i.e., "child mental health literacy"). As gatekeepers to recognition, treatment and management strategies, adults' knowledge and beliefs are arguably more important than the child's own knowledge and beliefs. In addition, we consider MHLSC to be different to mental health promotion, as the knowledge, attitudes and skills required to promote good mental health in childhood are fundamentally different (though closely related) to those required for the recognition, prevention or management of mental ill-health. Since its conceptualization in the 1990s, MHL research has grown in size and impact. In the late 2000s, there was a shift in focus from the knowledge and beliefs that adults held about their own mental health towards literacy for adolescent mental health. Population surveys around the world soon examined how youth understood and sought help for their mental health, and how interventions could improve their MHL. MHL is now considered "the foundation" for prevention, early identification, intervention, and ongoing care for mental ill-health3. Indeed, it is now inconceivable that any national strategy on mental health would omit MHL, given its necessity in fostering appropriate help seeking, management and prevention of mental health problems. Mental ill-health, however, is not only common among adolescents and adults. Around 13% of children experience a diagnosable illness in any 12-month period5, 7. Recent global estimates suggest that 35% of all mental illnesses begin before age 148. Yet, a persistent issue encountered in the "paediatric", "child and adolescent" or "youth" mental health literature is that sample age tends to be ill-defined; some studies sample infants through to those aged 18 years, while others include pre-school or school age through to young adulthood (25 years)7. An entrenched proclivity in this approach is to prioritize adolescents while younger children are ignored9. What the history of MHL research shows us, however, is that with precise conceptualization we can identify knowledge gaps, understand attitudes, and highlight help-seeking barriers, which can then be effectively targeted by interventions. But until MHL research can illustrate the necessary focus on children aged 5 to 12 years, advancements in policy and funding to improve outcomes in child mental health will remain out of reach. We are confident that articulating the scope and need for a new field of MHLSC research will lead to new high-quality measures, representative population-level surveys, effective interventions, and evidence-based policy targets, just as it has for adult and adolescent mental health globally. If history repeats itself, this new research endeavour will help us improve the mental health outcomes for the children of the future.